1202NRS: Rani is a 52 year-old-man who lives in Jakarta

Rani is a 52 year-old-man who lives in Jakarta, Indonesia and is employed as a marine engineer. He recently separated from his wife, Subi, after 16 years of marriage. Rani and Subi have two daughters who they co-parent. Rani’s elderly father, Harto, lives with Rani. The ship Rani works on operates between Indonesia and China. Having worked together on the ship for years, Rani had developed a close friendship with the ship’s captain, Vikal.

During one trip the ship set off from Shanghi, planning to stop at Hong Kong and Singapore before sailing home to Jakarta. During a period of particularly rough seas, Rani slipped on the deck, bumped his head on a storage container and landed heavily on his back. After a couple of minutes, he eventually managed to stand up and continued working.

Two days later the ship berthed at the port in Hong Kong. At that time Rani complained of a severe headache, neck pain and generally feeling unwell. He attended the local medical centre where he was diagnosed as having a musculoskeletal injury and advised to rest. He was provided with a prescription for oxycodone, a narcotic, and a non-steroidal anti-inflammatory for his symptoms. The ship then departed for Singapore, arriving four days later. During this time, Rani’ pain head and neck pain worsened and Vikal decided that he should be reviewed again before they set off on the longest leg of their journey. Rani did not want to be a burden, and despite the ongoing pain, said he would stay on the ship while it was in port.

Unconvinced, Vikal radioed the Singapore Port Communication Tower requesting an ambulance to transport Rani to hospital for further assessment. When Vikal told Rani that the ambulance was on its way, Rani was very annoyed. Keen to show that he did not require any additional medical treatment Rani took four oxycodone tablets and four anti-inflammatory tablets.  He thought that this would help the pain and convince Vikal and the paramedics that no further treatment was required. However, when the paramedics arrived, Vikal ordered Rani to go to the hospital for further investigation. On visual inspection, it was apparent to the paramedics that Rani needed further assessment and possible treatment as he was pale and sweaty, and quite unsteady in his gait.

Rani disembarked the ship slowly, and clumsily, made his way to the waiting ambulance. Once there, he refused to let the paramedics examine him, aggressively asking that they transport him as quickly as possible to get this ‘whole thing over with’. Vikal apologised to the paramedics stating that this behaviour was quite out of character. En route to the hospital, the paramedics asked several times whether Rani would allow them to take a set of observations, but he refused.

Arriving at the Emergency Department, the paramedics provided the triage nurse with a summary of Rani’s condition. Rani remained uncooperative, refusing to allow the nursing staff to assess him. Rani did see a doctor but made it very clear that he was only there under the orders of his Captain and wished to return to the ship. Given his lack of cooperation, there was little that any of the healthcare practitioners at the hospital could do to assist Rani and he walked out of the department without being properly examined.

Rani returned to the ship and reported to Vikal that he had seen the doctor and that there was nothing more they could do but ‘give it some time’. Vikal’s understood this to mean that Rani would eventually improve with the medication he had been prescribed. He was not concerned when Rani retired to his cabin.

In the cabin Rani, he began to feel nauseous and the pain escalated. To relieve it, Rani took more oxycodone tablets. While having a mild effect on the pain, the oxycodone exacerbated the nausea and began to make Rani feel disorientated. Feeling as though he needed to vomit, he made his way up onto the deck. In his disorientated state, he did not notice that he had stepped beneath a crane that was unloading cargo onto the ship’s deck. As he lurched to vomit over the edge, the crane released its cargo, which landed directly on top of Rani. One of the crew saw the cargo fall and on Rani and immediately called the ambulance. In the meantime, all efforts were made to move the cargo that was crushing Rani.

Upon arrival, the paramedics assessed Rani as having facial and skull fractures with bleeding and bruising, a suspected traumatic brain injury, fractured ribs and possibly a pneumothorax. As Rani was minimally responsive and bleeding profusely, they immediately intubated him, attempted to arrest the bleeding, and transported him back to the hospital in Singapore.

CT scans confirmed multiple skull and facial fractures, a large subarachnoid haemorrhage and a left pneumothorax, and Rani was admitted to the intensive care unit (ICU). In the meantime, Vikal contacted Subi and Harto who made urgent plans to fly to Singapore with the children. However, the flight was delayed and the family were not there when Rani was wheeled to surgery to fix the facial fractures and evacuate the haematoma.

Unfortunately, after several weeks in ICU, Rani’s progress was poor, and the chances of a full recovery became increasingly slim. A tracheostomy tube was inserted, but despite several attempts, he could not be weaned from the ventilator. Rani no longer moved spontaneously or responded to any of his family. As weeks turned into months, Subi began to accept that Rani might not return to his former self.

The healthcare team caring for Rani formed the opinion that he was in a minimally conscious state.They believed that because of the extensive traumatic brain injury Rani had no awareness ofhis surroundings, and as long as he remained unable to breathe on his own there was no possibility of recovery. Subi agreed with the assessment made by the healthcare team, believing that Rani displayed no sign of recognising anyone, or even that people were there with him at all. She described Rani’s condition, saying that, ‘initially you could think that he might notice you were there, but it was really like he was asleep on the inside and just startling at noise or contact’. Subi insisted that she and Rani had discussed how they would want to be treated if they were ever to be involved in a significant accident. Rani had been adamant that he would not want to be left in a situation where he could not care for himself, would be a cause of distress to his family, and would be unable to provide for the people he loved the most. Subireported thatRani had said ‘if that ever happens, please just turn the bloody machines off’.

Feeling somewhat responsible for Rani’s accident, Vikal stayed by his bedside for long periods. Vikal’s perception of Rani’s situation was quite different. He did not agree that Rani had no awareness of his surroundings and thought that from time to time he would try to turn his head when he heard the children’s voices – not always, but sometimes. He had undertaken some research and found several cases in which people had ‘woken up’ after being in comas for prolonged periods, and several more in which people had substantially recovered from traumatic brain injury. Vikal discussed this with Harto and although they also knew that Rani would not want to remain reliant on others’ care in the long term, they were hopeful that given time and encouragement, Rani would be able to communicate with his family, if not return to his prior self entirely.

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Subi and the healthcare team caring for Rani believed that continuing treatment was not in his best interests and concluded that all treatment should stop. Vikal and Harto, however, were opposed to stopping treatment; they wanted Rani to be given every opportunity to recover, even if that meant that he needed to remain highly dependent in hospital for many more months or years.

You are required to answer the following questions as a structured essay with the following headings.

Introduction

A short introductory paragraph that outlines what you will be presenting in your essay.

You do not need to include a detailed account of the facts in the scenario; the markers are aware of the scenario and this is an unnecessary use of your word count.

Ethical Issues

Using structured sentences and paragraphs, you are required to:

1. Identify one value that Subi may have and, referring to appropriate academic literature, describe this value.

2. Identify one value that Vikal may have and, referring to appropriate academic literature, describe this value.

3. Discuss how the different beliefs or values held by Subi and Vikal may contribute to their different points of view on Rani’s ongoing care.

Legal Issues

Using structured sentences and paragraphs, answer the following questions about the legal issues raised by the case.

4. What elements must be present for Rani’s consent to treatment for his musculoskeletal pain to be valid?

a. What legal authority can you rely upon to support your answer?

b. What potential legal consequences may flow if healthcare practitioners provide treatment without first obtaining consent?

5. As Rani had previously refused treatment for the pain he experienced after he slipped on the deck, do the paramedics have any legal authority to institute treatment for his head injury?

a. What legal authority can you rely upon to support your answer?

6. Unless it is an emergency, it is a legal requirement that healthcare practitioners obtain consent for all medical treatment. Provide a rationale for the legal obligation to obtain consent for Rani’ tracheostomy in these circumstances.

7. List the legal options available for the healthcare practitioners to obtain consent for Rani’s ongoing care in the ICU. Support your answer with the Singaporean legal authority.

8. What factors will be taken into account when deciding whether Rani’s life-sustaining measures can be withdrawn?

ETHICAL ISSUES

Criterion One

Accurately identifies one belief or value that Subi may have and uses appropriate academic literature to provide a comprehensive description of this value or belief.

Criterion Two

Accurately identifies one belief or value that Vikal may have and uses appropriate academic literature to provide a comprehensive description of this value or belief.

Criterion Three

Provides a well-reasoned and structured discussion of how the different values and beliefs held by Subi and Vikal may contribute to their different points of view on Rani’ ongoing care.
LEGAL ISSUES

Criterion One

Using appropriate legal authority correctly describes the elements of valid consent and the potential legal consequences that may flow if healthcare practitioners provide treatment without consent.

Criterion Two

Correctly identifies whether the paramedics have authority to treat Rani in light of his earlier refusal and provides correct legal authority to support the answer.

Criterion Three

Provides a rationale to support the legal requirement to obtain consent in circumstances where a patient lacks decision-making capacity.

Criterion Four

Correctly lists the potential options available for healthcare practitioners to obtain consent for Rani’s ongoing care in the ICU and provides the correct legal authority to support the answer.

Criterion Five

Correctly describes the factors that will be taken into account when deciding whether Rani’ life-sustaining measures can be withdrawn.

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